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Glossary

Comminuted fractures often result from crushing or high-energy injuries and may include several metacarpals. Compartment syndrome may occur with these types of injuries, and fasciotomy may therefore be necessary. These fractures are very unstable.

Bridge plating

Bridge plating uses the plate as an extramedullary splint fixed to the two main fragments, while the complex fracture zone is bridged. The dissection required for anatomical reduction of all fragments would risk disturbing their blood supply and is not necessary. If the soft-tissue attachments of these fragments are preserved, and they are relatively well aligned, healing is predictable. Occasionally, a larger wedge fragment can be fixed to one of the main fragments using a lag screw. However, it is important
to restore axial alignment, length and correct rotational alignment of the main shaft fragments.
Relative mechanical stability, provided by the bridging plate, leads to healing by callus formation.

Multiple metacarpal fractures

When multiple metacarpals are injured, restoration of length and rotation is difficult. If one of the finger metacarpals is intact, the fixation is started on the adjacent metacarpal, and then continued sequentially.

The fracture is reduced by using longitudinal traction on the finger, manually, using a finger trap, or with pointed reduction forceps. Additional pressure can be exerted on the metacarpal head from the palmar aspect.

Restoration of length

Check for correct rotation

Correct rotation has to be checked with the metacarpophalangeal (MCP) joints flexed to detect any overlapping of the fingers.
Flexing the MCP joints whilst preventing overlap of the fingers will reduce a rotational displacement.

Plate selection

The plate should be long enough to allow for 2 screws in each main fragment.
Usually, 2 mm plates are used for the fixation of the metacarpals. For comminuted fractures, 2.4 mm plates may be indicated.
As these fractures are very unstable, more stable fixation devices may be preferable, such as the Locking Compression Plate (LCP).
If the fracture zone extends far distally or proximally, a T-plate, or minicondylar plate, may be indicated.

Pitfall

Plate application

The plate is applied dorsally onto the metacarpal in its long axis. Correct rotational alignment of the distal main fragment may be difficult to achieve but is essential.
Ensure that at least 2 screw holes come to lie over each of the main fragments.

Measuring

Screw insertion

Insert the first screw. Ensure that it engages the far cortex. Failure to take accurate measurement of the required screw length risks not engaging the far cortex, thereby weakening the fixation and creating the risk of implant failure.

Insert second screw

Make sure that the plate is correctly aligned in the longitudinal axis of the metacarpal. Insert a second neutral screw into the distal main fragment after the same fashion as above.
Confirm correct axial alignment and length using image intensification. Check correct rotation by flexing all fingers at the MCP joints.